A nurse is assessing a client who is at 33 weeks of gestation.
Which of the following findings should the nurse report to the provider?

Choice A rationale

Cooling the newborn's heel causes vasoconstriction, which reduces blood flow to the area. This would make it more difficult to obtain an adequate blood sample and could lead to repeated punctures, increasing the risk of discomfort and tissue damage for the newborn. Optimal blood flow is crucial for a successful heel stick.

Choice B rationale

Puncturing the center of the newborn's heel risks damaging the calcaneus bone, which can lead to osteomyelitis, an infection of the bone. The proper technique involves puncturing the lateral aspects of the heel to avoid bone injury and ensure patient safety.

Choice C rationale

Cleansing the puncture site with an alcohol gauze pad prior to the procedure is essential for asepsis. Alcohol acts as an antiseptic by denaturing proteins and dissolving lipids in bacterial cell membranes, effectively reducing the microbial load on the skin surface and minimizing the risk of introducing pathogens into the bloodstream during the puncture.

Choice D rationale

Administering vitamin K is typically done shortly after birth to prevent hemorrhagic disease of the newborn, as newborns have immature livers and insufficient gut flora for vitamin K synthesis. It is not routinely administered 30 minutes prior to every blood draw and is unrelated to the immediate procedure of obtaining a heel stick sample.

Complete the sentence: The nurse should massage the uterus and prepare to administer oxytocin.

Rationale for correct answers:
Uterine atony is the most common cause of postpartum hemorrhage (PPH), indicated by a boggy uterus and heavy bleeding with clots. Uterine massage stimulates uterine contractions, promoting involution and reducing bleeding. Oxytocin is a first-line uterotonic agent that increases uterine tone by stimulating smooth muscle contraction, helping to control hemorrhage. Normal hemoglobin is 11-16 g/dL; the client’s drop to 9.4 g/dL and hematocrit decrease to 27% (normal 33%-47%) indicate blood loss requiring prompt intervention.

Rationale for incorrect Response 1 options:
Inserting an indwelling urinary catheter is unnecessary here because the client emptied her bladder without difficulty, and urinary retention is not evident. Oxygen administration by nasal cannula is not indicated since the client’s respiratory rate is normal and there is no sign of hypoxia. Immediate oxygen is reserved for hypoxic or unstable patients.

Rationale for incorrect Response 2 options:
Administering oxygen by nasal cannula is not needed without hypoxia signs. Initiating a 1000 mL sodium chloride bolus might be considered later if hypovolemia or hypotension worsens but is not the immediate priority. Inserting an indwelling urinary catheter is not indicated as the bladder is emptying normally, and unnecessary catheterization risks infection.

Take-home points:

• Postpartum hemorrhage is primarily caused by uterine atony, presenting with a boggy uterus and heavy bleeding.
• Prompt uterine massage and administration of oxytocin are critical first-line interventions to control bleeding.
• Laboratory values such as hemoglobin and hematocrit help assess blood loss severity and guide management.
• Differentiation from other causes of bleeding (e.g., retained placenta, lacerations) requires assessment but initial treatment focuses on uterine tone restoration.